TO USE IN MAIL ORDER OR NON-PARTICIPATING PHARMACIES

If your mail order pharmacy does not accept the savings card, follow these simple steps after activating your card:

Call your mail order pharmacy to see if they accept the savings card. If they do, provide them with your savings card ID number after they receive your prescription. You will receive your check when the pharmacy processes your prescription payment.

If your mail order or retail pharmacy does NOT accept the savings card:

When you receive this form, complete and sign it. Then mail this form along with the original mail-order pharmacy receipt (cash register receipts are not acceptable) to the address listed on the form. Forms submitted without the original mail-order pharmacy receipt will not be valid and therefore will not be eligible for reimbursement.

Remember to keep a copy of your receipt for your records. You should receive your check in about 6 to 8 weeks.

You will need to submit a patient rebate form each time you get a refill of your prescription and complete step 2B to receive your check.

You may be eligible for this offer if you are insured by commercial insurance and your insurance does not cover the full cost of your prescription, or you are not insured and are responsible for the cost of your prescriptions. Patients who are enrolled in a state or federally funded prescription insurance program are not eligible for this offer. This includes patients enrolled in Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DOD) programs or TriCare, and patients who are Medicare eligible and enrolled in an employer-sponsored group waiver health plan or government-subsidized prescription drug benefit program for retirees. If you are enrolled in a state or federally funded prescription insurance program, you may not use this savings card even if you elect to be processed as an uninsured (cash-paying) patient. This offer is not insurance, is restricted to residents of the United States and Puerto Rico, and to patients over 18 years of age.

TERMS OF USE:

Eligible commercially insured patients with a valid prescription for ONGLYZA® (saxagliptin) or KOMBIGLYZE® XR (saxagliptin and metformin HCl extended-release) who present this savings card at participating pharmacies will pay as low as $0 per 30-day supply subject to a maximum savings of $150 per 30-day supply. If you pay cash for your prescription, AstraZeneca will pay up to the first $150, and you will be responsible for any remaining balance, for each monthly prescription. Other restrictions may apply. Patient is responsible for applicable taxes, if any. Non-transferable, limited to one per person, cannot be combined with any other offer. Void where prohibited by law, taxed or restricted. Patients, pharmacists, and prescribers cannot seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this offer. AstraZeneca reserves the right to rescind, revoke, or amend this offer, eligibility and terms of use at any time without notice. This offer is not conditioned on any past, present or future purchase, including refills. Offer must be presented along with a valid prescription at the time of purchase. If you have any questions regarding this offer, please call 1-855--907-31971-855-907-3197.

BY USING THIS CARD, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.

Pharmacist Instructions for a Patient with an Eligible Third Party:

For Insured/Covered Patients: Submit the claim to the primary Third-Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 8. This will reduce the eligible patient’s out-of-pocket costs to as low as $0 per 30-day supply subject to a maximum savings limit for the program, patient out-of-pocket expenses may vary. Reimbursement will be received from Change Healthcare.

Pharmacist Instructions for Insured/Not Covered Patients: Submit the claim to the primary Third-Party Payer first, if the primary claim submission shows a managed care restriction (step-edit, prior authorization or NDC block), continue the claim adjudication process and submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 3. This will reduce eligible patient’s out-of-pocket costs to as low as $0 per 30-day supply subject to a maximum savings limit for the program, patient out-of-pocket expenses may vary. Reimbursement will be received from Change Healthcare.

Pharmacist Instructions for a Cash-Paying Patient: Submit this claim to Change Healthcare. A valid Other Coverage Code (eg, 1) is required. The card will cover up to $150 per 30-day supply. Reimbursement will be received from Change Healthcare.

Valid Other Coverage Code Required. For any questions regarding Change Healthcare online processing, please call the Help Desk at
1-800--422-56041-800-422-5604.